Answering your questions on Chronic Myeloid Leukaemia (CML)

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Answering your questions on
Chronic Myeloid Leukaemia (CML)
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Your guide to
understanding CML and
Glivec® (imatinib) treatment
The information in this booklet is designed to help you
understand chronic myeloid leukaemia (CML) and Glivec,
the treatment your doctor has prescribed.
Understanding your disease and its treatment, and
knowing what to expect, are important. You are sure to
have many questions so, as well as reading this booklet,
talk to your doctor about how you feel and any problems
you may experience.
Remember:
Medicines only
work in people
who take them
It is also vital that you continue to take Glivec every day for
as long as your doctor prescribes it, even when you feel well.
Glivec specifically targets the abnormality that causes CML
and, like any medicine, it can only be effective if you continue
to take it. Regular appointments with your doctor are
important to make sure the treatment is working.
You may also want to contact other people with CML or
support groups dedicated to helping people with cancer,
and their families. Contact details are provided at the end
of this booklet.
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Table of contents
What is Chronic Myeloid Leukaemia?
2
Formation of blood cells
2
Diagnosis of CML
3
How CML develops
4
Formation of the Philadelphia chromosome
5
The three phases of CML
7
How is CML treated?
8
Stem cell transplantation
8
Interferon alpha
9
Chemotherapy
10
Glivec
10
All about Glivec
12
How Glivec works
12
What Glivec treatment can achieve
12
Why you must see your doctor regularly
13
Monitoring your response to treatment
13
Understanding your test results
14
How to take Glivec
15
Side effects that may occur
16
Glivec and other drugs
21
Diet and lifestyle
22
Getting emotional and practical support
23
Answers to your questions about Glivec
25
Where to get more information and support
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What is Leukaemia and
Chronic Myeloid Leukaemia?
Leukaemia is a type of cancer of the blood and bone marrow
- the spongy tissue inside bones, where blood cells develop.
As a result of the disease, the body produces too many
white blood cells, most of which are abnormal.
Chronic Myeloid Leukaemia (CML) is one type of
leukaemia. ‘Chronic’ means it is a slowly growing cancer
that may take years to progress. ‘Myeloid’ refers to the
type of white blood cells being overproduced.
So Chronic Myeloid Leukaemia is a slowly progressing
cancer that results in the body producing too many white
blood cells of the myeloid type.
Formation of blood cells
Bone marrow contains stem cells, which develop into
three types of blood cells: red blood cells, white blood
cells and platelets.
Normal blood development
The stem cells receive signals which turn them on and off
as necessary to produce the exact number of blood cells
that the body needs.
Myeloid stem cells
Myeloid white blood cells
Lymphoid stem cells
Diagnosis of CML
CML is a rare form of leukaemia. There are around 250 to
300 new cases diagnosed each year in Australia and 50
new cases in New Zealand. The average age of people
diagnosed with CML is 50 to 60 years. It affects men and
women equally but is very rare in children.
In most cases the cause of CML is unknown, however
exposure to high levels of radiation may play a role in a
small number of individuals. Like other forms of
leukaemia, CML does not run in families.
Often CML is first diagnosed during a routine blood test,
before any symptoms occur. Then a bone marrow sample
is usually taken, to confirm the diagnosis.
Platelets
help blood to clot
Lymphoid white blood cells
These cells fight infection
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leukaemia, CML does
not run in families.
Stem cells (in bone marrow) divide and mature into different types of blood cells
Red blood cells carry oxygen
to other cells in the body
Like other forms of
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What is Leukaemia and
Chronic Myeloid Leukaemia?
People with CML
How CML develops
Formation of the Philadelphia chromosome
CML progresses
have an abnormal
People with CML have an abnormal chromosome in their
myeloid stem cells and white blood cells. It is called
the Philadelphia chromosome, and it is made up of small
parts of two normal chromosomes switching places as
shown in the diagram below. This abnormal Philadelphia
chromosome initially develops in a single myeloid
stem cell - the first ‘leukaemic cell’. This cell then
multiplies to form thousands and eventually millions of
daughter leukaemic cells all containing the Philadelphia or
Ph chromosome.
The formation of the Philadelphia chromosome creates a
new gene called bcr-abl (pronounced bee-see-are able).
This gene controls the production of an abnormal protein
called the BCR-ABL protein, which blocks the signals that
tell the stem cells to stop producing myeloid white cells.
This leads to extremely high levels of myeloid white cells
circulating in the blood stream.
through three
chromosome in their
myeloid stem cells
and white blood cells
Formation of the Philadelphia chromosome
Normal
Abnormal switch
Philadelphia chromosome
Chromosome 9
Philadelphia (Ph)
chromosome
abl gene
bcr-abl gene
Chromosome 22
bcr gene
A piece of chromosome 9 and a piece of
chromosome 22 switch places
Controls the production of
BCR-ABL protein
The switch results in the formation of the Philadelphia, or Ph chromosome.
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5
phases: the chronic
phase, the
accelerated phase
and the blast phase
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What is Leukaemia and
Chronic Myeloid Leukaemia?
The three phases of CML
CML progresses through three phases: the chronic phase, the accelerated phase
and the blast phase.
1. Chronic Phase
Symptoms When newly diagnosed,
there are often few
or no symptoms.
Sometimes fatigue,
sweats, weight loss and
enlarged spleen* occur.
2. Accelerated Phase
3. Blast Phase
Worsening of symptoms.
Fatigue, easy bruising,
fever, night sweats,
infection, bone pain,
abdominal pain and
enlarged spleen and liver.
Symptoms get
progressively worse.
Fatigue, bleeding,
fever, weight loss and
complications related
to infection may occur.
Signs
in blood
White blood cell count
is higher than normal.
A few blast cells**
are found in blood
and bone marrow.
Increase in number
of blast cells in blood
and bone marrow.
Red blood cells and
platelets may decrease.
Further increase in
number of blast cells
in the blood and bone
marrow. Crowding
reduces production
of normal red blood
cells and platelets.
Blast cells may spread
to other organs
Length
of phase
without
Glivec®
Often 5 years or more
6–9 months
3–6 months
*
The spleen is an organ on the upper left hand side of the stomach. It removes damaged red
blood cells from the circulation and makes some of the white blood cells.
** ‘Blast’ cells are ‘immature’ cells that develop into mature white blood cells.
The aim of treatment of CML is to eliminate as many of the leukaemia cells with the Philadelphia
chromosome as possible.
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How is CML treated?
Allogeneic stem cell transplantation from a well-matched
There are a range of treatment options:
– stem cell transplantation
Interferon alpha
donor is the most common type of transplantation used in
is given by injection
– drug therapies - such as chemotherapy,
interferon alpha and Glivec
provide a cure for CML in some patients. However, there
– a combination of the above
CML. It is the only treatment that is currently proven to
and can slow the
are risks associated with the procedure, and it is not
growth of leukaemia
suitable for everyone, especially older people. The high
cells in blood and
dose chemotherapy often causes side effects including
bone marrow.
Stem cell transplantation
(also called bone marrow transplantation)
hair loss and nausea, and can sometimes result in
Stem cell transplantation firstly involves high dose
chemotherapy, with or without radiotherapy, which kills all
the cells in the bone marrow (normal stem cells as well as
leukaemia cells). These cells are then replaced with a
transfusion of normal stem cells which may be obtained
from the bone marrow or blood stream.
complication of allogeneic transplants is ‘graft versus host
A) Allogeneic stem cell transplantation
Interferons are natural substances produced by some
This is where stem cells are donated from someone who
has stem cells that are considered ‘well matched’ or
compatible to the person’s own. This could either be a
family member or an unrelated donor.
white blood cells to help fight infection. Although the exact
B) Autologous stem cell transplantation (‘autograft’)
prolong life in some cases of CML. Interferon alpha is
This is where the person’s own stem cells are collected
(‘harvested’) when they have shown a good initial response
to drug treatment. The stem cells are stored
so that they can be re-infused if they are needed later
on. This is still a relatively rare procedure and regarded
as experimental.
sometimes given alone, and sometimes with the cytotoxic
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infection and organ failure. A common and often serious
disease’ in which the donor stem cells react with the
person’s own cells, causing damage to liver, skin and
other organs.
Interferon alpha
action of interferon alpha is not fully understood in CML, it
is given by injection and can slow the growth of leukaemia
cells in blood and bone marrow. It has been shown to
drug cytarabine (ara-C).
Some people cannot tolerate the side effects of interferon
therapy, however, better tolerated formulations are
being developed.
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How is CML treated? continued
Glivec is a relatively
Chemotherapy (i.e. hydroxyurea/busulfan)
new treatment for
Chemotherapy is the use of cytotoxic (anti-cancer) drugs
to destroy or control the leukaemia cells. Chemotherapies
such as hydroxyurea and busulfan are usually used
when drugs such as Glivec or interferon are not working
as well as expected, or if a person is being prepared
for transplantation.
CML that specifically
targets the genetic
abnormality that
causes CML.
They are used to help reduce the number of myeloid white
cells in the blood and to treat some of the symptoms of
CML, but have not been shown to prolong life.
Hydroxyurea is also sometimes used while a patient is
waiting to begin treatment with Glivec, to help control the
number of white blood cells in circulation.
Glivec® (imatinib)
Glivec (also known in the United States as Gleevec®) is a
relatively new treatment for CML that specifically targets
the genetic abnormality that causes CML.
Comprehensive information on Glivec is provided in the
following pages.
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All about Glivec
How Glivec works
Why you must see your doctor regularly
Even when you are
Glivec targets the cause of CML by blocking the action of
the BCR-ABL protein. This protein interferes with the signal
to the stem cells in the bone marrow to stop producing
myeloid white blood cells.
Glivec has not been proven to cure CML. However, if you
keep taking it as prescribed, it can usually keep CML
under control.
feeling well, it’s
In this way, Glivec can decrease the number of white blood
cells being produced and cause the leukaemia cells with
the Philadelphia chromosome to undergo cell death.
Because Glivec acts specifically on the abnormality that
causes CML, it is less likely to affect normal cells than
other drug therapies used to treat cancer.
With regular monitoring, your doctor can evaluate how
well your blood and bone marrow are responding to
Glivec, assess possible side effects and make any
necessary adjustments to your treatment. So, even when
you are feeling well, it’s important that you keep your
regular follow-up medical appointments.
Monitoring your response to treatment
What Glivec treatment can achieve
Some tests your doctor may do include:
The primary goal of Glivec therapy is to eliminate
leukaemia cells with the Philadelphia chromosome.
• A blood test to measure your level of white
blood cells, red blood cells and platelets.
Glivec has not been proven to ‘cure’ CML, but it has rapidly
reduced the disease in many patients with chronic phase
CML and has returned some patients with more advanced
disease to the chronic phase.
• A bone marrow test to measure the number
of cells that contain the Philadelphia chromosome.
It is important to remember that patients respond
differently to therapy. How you respond to Glivec will
depend on many factors, but your doctor has prescribed
Glivec for you because he or she believes it is the right
treatment for you.
• A blood or bone marrow test to measure the
amount of BCR-ABL present in the body, which
indicates the number of leukaemia cells in the body.
• Your doctor may also weigh you on a regular
basis and send you for other tests, such as liver
function tests, to make sure that your body is
not reacting to Glivec in an unexpected way.
To obtain the best chance of a good response to
treatment, it is essential that Glivec tablets are taken
continuously, exactly as prescribed by your doctor.
Visits to your doctor are also a good opportunity to ask
questions and discuss any concerns you may have.
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important that you
keep your regular
follow-up medical
appointments.
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All about Glivec
continued
Understanding your test results
A Complete Haematological Response (CHR) means that
all blood cell types have returned to normal levels.
During a haematological response, the leukaemic cells
containing the Philadelphia chromosome may still be present.
A Major Cytogenetic Response (MCR) means that the
number of leukaemia cells with the Philadelphia
chromosome has been considerably reduced i.e. the
number of these cells has been reduced from levels as
high as 100% at the start of treatment to levels between
1% and 35%.
A Complete Cytogenetic Response (CCR) means that
none of the leukaemia cells with the Philadelphia
chromosome are able to be detected by standard
laboratory methods used to look at chromosomes within
cells i.e. Philadelphia chromosome levels of 0%.
A Major Molecular Response (MMR) means that the
levels of BCR-ABL have been reduced by at least 1,000
times from an average level seen in patients when they are
first diagnosed with CML.
The test that is used to detect the level of BCR-ABL in blood
or bone marrow is called Polymerase Chain Reaction (PCR).
PCR-negativity is when the levels of BCR-ABL are reduced to
such an extent that they cannot be detected using highly
sensitive PCR measurements. This usually reflects a reduction
in BCR-ABL of at least 10,000 times from an average level
seen in patients when they are first diagnosed with CML.
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However, there may still be some leukaemia cells
remaining that cannot be detected and it is important to
continue taking your Glivec as prescribed by your doctor
to help keep the disease under control.
Glivec is taken
How to take Glivec
Taking your Glivec
Glivec is taken in tablet form, usually once a day. However, your
doctor may recommend that you take the tablets in two doses,
one in the morning and one in the evening. Taking your Glivec
at the same time each day helps you to remember to take it.
at the same time
Glivec is available as 100mg tablets and 400mg tablets.
to take it.
100mg tablet
400mg tablet
Your doctor will have prescribed the appropriate dose for
your stage of CML and may change this dose depending
on your response to treatment.
How to take your Glivec tablets:
• Usually once a day, at around the same time each day
• Never take Glivec on an empty stomach - always
take it with a substantial meal and a large glass
of water
• Glivec should not be taken with grapefruit juice
• Talk to your doctor before taking any other
medicine or supplements
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in tablet form,
usually once a day.
each day helps
you to remember
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All about Glivec
To make sure your
Glivec treatment can
continued
To make sure your Glivec treatment can be effective, you
have the important responsibility of taking it every day at
the dose your doctor has prescribed.
be effective, you
have the important
responsibility of
taking it every day at
the dose your doctor
has prescribed.
It is possible that, because of occasional side effects, you
will want to take less of your medicine, or not take it at all.
However, it is very important for you to continue taking
Glivec as instructed, unless your doctor has told you to
stop treatment or to reduce the dose.
Side effects that may occur
In most people taking Glivec, side effects are mild
to moderate. They often occur during the first month
or two of treatment and may then decrease after this
initial period.
The most common side effects are mild nausea, vomiting,
diarrhoea, fatigue, headache, fluid retention, rash, muscle
pains and cramps.
Each person’s reaction to an anti- cancer drug is different.
Some people may have very few side effects, while others
may experience more. Tell your doctor about any side
effects you have while taking Glivec. In most cases, side
effects can be reduced with advice and treatments
recommended by your doctor.
Important side effects are discussed in the following section.
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All about Glivec
continued
Fluid retention
Nausea and vomiting
Taking Glivec with
A common side effect with Glivec therapy is fluid retention,
also known as oedema. It is most common around the eyes
but may also be seen in the ankles or legs.
Nausea and vomiting is fairly common, especially when
first starting Glivec. Heartburn (dyspepsia) may also
be experienced quite frequently. Taking Glivec with a
substantial meal and a large glass of water may minimise
these effects. Splitting higher doses in two (morning and
evening) may also help.
a substantial meal
Occasionally a build up of fluid may occur in other parts of
the body, including the lungs, heart and abdomen. Your
doctor will monitor you closely and weigh you on a regular
basis to prevent complications from occurring.
If you notice any increase in weight or swelling anywhere
in your body while taking Glivec, notify your doctor. You
may be given a drug called a diuretic which can help
reduce the amount of fluids in your body.
Fatigue and anaemia
A feeling of fatigue and tiredness is very common when
starting Glivec, and although this generally becomes less
noticeable over time, some people do experience it for longer.
It is also common for people to develop anaemia (which
means that the blood is less able to carry oxygen to the
body, and is sometimes due to low levels of red blood
cells or iron). This may add to the feeling of lethargy.
Headache
Headaches are a common side effect affecting more than
1 in 10 people taking Glivec. Talk to your doctor if they are
severe or become more frequent.
Muscle cramps
Muscle cramps and spasm are usually mild and can
generally be managed with electrolyte supplements. If you
develop severe muscle cramps while taking Glivec,
contact your doctor.
Muscle, bone, and joint pain
Some patients have experienced muscle and bone pains
as well as joint pain and swelling while taking Glivec. If you
have any pain during treatment, contact your doctor.
Dry skin
Diarrhoea
If you experience diarrhoea during Glivec therapy, contact your
doctor before taking any other drugs. Diarrhoea is usually mild
and may be managed with over-the-counter medications.
Dry, flaky skin has occurred in some patients taking
Glivec. This may be helped by using a moisturising cream
or bath oil. If this is necessary, ask you pharmacist or
doctor for their recommendation.
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and a large glass of
water may minimise
these effects.
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All about Glivec
continued
Skin rash
Glivec and other drugs
It is very important
Some patients taking Glivec may develop a skin rash. If
you notice any red patches, itchiness, or blistering,
contact your doctor. You may be given an additional
medication, such as an antihistamine or a topical
corticosteroid cream, to reduce the rash.
Glivec can affect, or be affected by, other medicines or
supplements you may be taking. When this happens,
Glivec or these other products may lose their
effectiveness or produce some unwanted side effects.
to talk to your doctor
Some drugs which may interact with Glivec include
warfarin, a medicine to prevent blood clots, certain
anticonvulsants to treat epilepsy (such as phenytoin or
carbamazepine), medicines for high cholesterol (such as
simvastatin), and certain antibiotics (such as
erythromycin, roxithromycin, clarithromycin, rifampicin,
ketoconazole and itraconazole).
are currently taking,
If additional treatment does not help and the rash
becomes severe, your doctor may find it necessary to
interrupt your Glivec therapy.
If you experience
Abdominal pain
side effects, please
It is fairly common for people to develop abdominal pain
while taking Glivec. If this is severe, contact your doctor.
consult your doctor.
Gastrointestinal (GI) bleeding
Do not stop taking
Glivec or change the
dose, unless your
doctor tells you to.
Although this is relatively rare in people taking Glivec for
CML, you should notify your doctor immediately if you
observe any blood in your stools or if your stools look very
dark in colour.
Other side effects not listed here may happen in some
people. Some of these side effects can only be found by
laboratory testing and your doctor will be taking blood
tests periodically to monitor your status.
Also included are dexamethasone (a steroid medicine),
cyclosporin (a medicine to suppress the immune system),
antiviral medicines used treat HIV/AIDS, and some
medicines used to treat depression or high blood pressure
and heart problems.
It is also recommended that paracetamol (e.g. Panadol®,
Panadeine®, Codral®, Tylenol®) is used with caution. In
addition, Glivec is known to interact with certain herbal
products such as St. John’s Wort [Hypericum peforatum].
Therefore, it is very important to talk to your doctor about
medications and supplements you are currently taking, or
are planning to take in the future.
Important note: You should avoid eating grapefruit or
drinking grapefruit juice while taking Glivec. Grapefruit
may increase the levels of Glivec in your blood.
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about medications
and supplements you
or are planning to
take in the future.
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All about Glivec
continued
Diet and lifestyle
Often simple changes to your diet and lifestyle can help
reduce side effects.
• Eat a healthy, balanced diet with fresh fruit and
vegetables. Good nutrition will help you cope
better with CML and your treatment, and to feel
better in yourself.
Good nutrition will
help you cope better
with CML and your
treatment, and to
feel better in yourself.
• To reduce nausea or diarrhoea, always take
Glivec with a meal, and avoid foods that you
know may upset your stomach such as spicy food.
• If it helps, take your Glivec with your main meal
when you feel hungry and eat lighter meals at
other times. You may prefer small frequent
snacks rather than large meals.
Getting emotional
and practical support
Getting emotional support during your treatment may be
just as important as getting medical treatment.
Everyone copes
Everyone copes differently with having CML and there is
no right or wrong way to react. At times you may feel
discouraged, angry, confused or depressed. You may
want to get as much information as possible on CML, or
you may just need someone to talk to. Your family and
loved ones may also have these feelings.
having CML and
There are a number of organisations and support groups
that can help you deal with practical problems relating to
transport, employment, social services, etc, as well as
providing emotional support.
Contact details are provided at the back of the booklet.
• Eat slowly and chew well to help you digest your
food better.
• Drink plenty of water and other fluids each day,
to avoid becoming dehydrated.
• Get some light exercise, such as walking.
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differently with
there is no right or
wrong way to react.
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Answers to your
questions about Glivec
Q. Will Glivec cure my CML?
A. Glivec has not been proven to ‘cure’ CML. However, if
you keep taking it as prescribed, Glivec treatment can
reduce the disease in many patients with chronic
phase CML and has returned some patients with more
advanced disease to the chronic phase.
Q. Can I stop taking Glivec or reduce the dose when
I feel well?
A. No. Feeling well means that the Glivec treatment is
likely to be keeping your CML under control. If you
stop taking Glivec, or reduce the dose, your body may
start producing large numbers of white blood cells
again and your CML will get worse. Always follow your
doctor’s instructions.
Q. Can I reduce the dose of Glivec if I get side effects?
A. You must not reduce your dose of Glivec unless your
doctor tells you to. If you have side effects, consult
your doctor before making any changes.
Q. Can I take other medicines together with Glivec?
A. Some medicines and Glivec may interfere with each
other. These include some medicines you buy without
a prescription from the pharmacy, supermarket or
health food shop. So you must tell your doctor if you
are taking, or want to take, any other medicines,
including paracetamol and herbal supplements.
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Answers to your
questions about Glivec
Q. Can I drink any alcohol while I am taking Glivec?
Q. What should I do if I forget a dose of Glivec?
Keep your Glivec in
A. Check with your doctor before consuming alcohol.
Alcoholic beverages may usually be taken with Glivec,
but the quantity should be limited to no more than one
or two units per day. However, alcohol and Glivec are
both processed by the liver. Your doctor may advise
you to avoid alcohol if he or she is concerned about
your liver health. In addition, if alcohol makes you feel
nauseous while taking Glivec, it is best to avoid alcohol.
A. Take the missed dose with some food as soon as you
remember and then continue taking the tablets at the
usual time each day. Don’t wait and take a double
dose to make up for the one you missed. If you’re not
sure what to do, ask your doctor or pharmacist.
its original container
Q. Should I take extra Glivec if I have vomiting
or diarrhoea?
will not get damp
Do not reduce
Q. Can I take Glivec if I am pregnant?
your dose of Glivec
A. No, you should not take Glivec if you are pregnant
or planning to become pregnant, because Glivec may
be harmful to your unborn baby. You must use
contraception if there is a chance of you becoming
pregnant, and tell your doctor immediately if you
become pregnant while taking Glivec.
unless your doctor
tells you to.
If it is necessary for you to take it during pregnancy,
your doctor will discuss the risks and benefits involved.
A. If you vomit or have diarrhoea after taking Glivec, ask
your doctor or pharmacist what to do.
Q. Can I drive while I am taking Glivec?
A. Although uncommon, some people get dizziness or
blurred vision when they take Glivec, so you should
make sure you are not affected in this way, before you
drive, operate machinery or do anything that could be
dangerous.
Q. Where should I store my Glivec?
A. It is not known whether Glivec passes into breast milk,
therefore breastfeeding is not recommended.
A. Keep your Glivec in its original container until you take
it. Store it in a cool, dry place where it will not get
damp or very hot. Make sure that young children
cannot reach it.
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Q. Can I take Glivec if I am breastfeeding?
until you take it.
Store it in a cool,
dry place where it
or very hot.
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Answers to your
questions about Glivec
Q. Do I need to protect my skin from the sun?
A. Glivec may cause your skin to be much more sensitive
to sunlight than it normally is. Exposure to sunlight can
cause skin rash, itching, redness or severe burning.
When you are outdoors you should wear protective
clothing and use at least a 15+ sunscreen. Do not use
a sunlamp.
Q. What if I am unable to swallow tablets?
A. Put the required tablet or tablets in a glass of water or
apple juice (approximately 50ml for a 100mg tablet,
and 200ml for a 400mg tablet). Stir with a spoon to
completely disintegrate the tablet or tablets and
immediately drink the whole contents of the glass.
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Where to get more
information and support
Leukaemia Foundation of Australia
Freecall: 1800 620 420
Enail:
[email protected]
Website: www.leukaemia.com
• www.novartis.com.au
“Answering your questions on CML” has been prepared by
Novartis Oncology, as an aid to patients and their families.
It has been reviewed by medical practitioners, patients
and health educators.
Some information in this booklet is derived from patient
information published by the Leukaemia Foundation
of Australia. Novartis Oncology gratefully acknowledges
their assistance.
Date of preparation: June 2005
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Prepared as a service to patients by Novartis Oncology.
Novartis Pharmaceuticals Australia Pty Ltd, ABN 18 004 244 160,
54 Waterloo Road, North Ryde, NSW 2113. ® = Registered trademark
Item No: 235315
GLIV 1916A BBK 06/05